Luxury Primary Care,Luxury Primary Care,Academic Medical Academic Medical Centers, and the Centers, and the
Erosion of Science and Erosion of Science and Professional EthicsProfessional Ethics
Martin Donohoe, MD, Martin Donohoe, MD, FACPFACP
Luxury Primary CareLuxury Primary Care IntroductionIntroduction
SourcesSources
ResearchResearch
Academic Medical Centers Academic Medical Centers Hurting FinanciallyHurting Financially
US health care crisisUS health care crisis
Costs associated with medical Costs associated with medical trainingtraining
Disproportionate share of complex Disproportionate share of complex and/or uninsured patientsand/or uninsured patients
Academic Medical Centers Academic Medical Centers Hurting FinanciallyHurting Financially
Erosion of infrastructureErosion of infrastructureShrinking funding baseShrinking funding base Increased competition Increased competition
with more efficient private with more efficient private and community hospitalsand community hospitals
Single Specialty Single Specialty HospitalsHospitals
Over 100 nationwideOver 100 nationwide Often physician-ownedOften physician-owned Problems:Problems:
Cherry pick healthier patients with good coverageCherry pick healthier patients with good coverage No ERNo ER Academic and community hospitals depleted of Academic and community hospitals depleted of
income stream used to cross-subsidize indigent care, income stream used to cross-subsidize indigent care, ER, trauma, burn wards, and mental health careER, trauma, burn wards, and mental health care
Incentives for overtreatmentIncentives for overtreatment >1/3 may violate Medicare’s conditions for >1/3 may violate Medicare’s conditions for
participationparticipation
Medical TourismMedical Tourism US citizens traveling abroad for care (750,000 US citizens traveling abroad for care (750,000
in 2007, estimated 1 million in 2010)in 2007, estimated 1 million in 2010) Insurance plans increasingly cover (large Insurance plans increasingly cover (large
cost savings)cost savings) Mostly for cardiac, orthopedic, and cosmetic Mostly for cardiac, orthopedic, and cosmetic
proceduresprocedures Sometimes for procedures unavailable or Sometimes for procedures unavailable or
illegal US (e.g., pharmaceuticals, PAS)illegal US (e.g., pharmaceuticals, PAS) Adverse effects on health care availability in Adverse effects on health care availability in
foreign countriesforeign countries
Medical TourismMedical Tourism 20,000 to 25,000 IVF procedures on US 20,000 to 25,000 IVF procedures on US
citizens done abroadcitizens done abroad Transplant Tourism:Transplant Tourism:
Black market for organs (10-25% of all Black market for organs (10-25% of all kidneys transplanted worldwide each year)kidneys transplanted worldwide each year)
Spurred on by marked organ scarcity in USSpurred on by marked organ scarcity in US Clinical and ethical issues of treating patients Clinical and ethical issues of treating patients
post-oppost-op Various legal approaches being considered in Various legal approaches being considered in
US to prosecuteUS to prosecute
Competitive StrategiesCompetitive Strategies Increase alliances with Increase alliances with
pharmaceutical and biotech pharmaceutical and biotech industriesindustries
Recruit wealthy, non-U.S. Recruit wealthy, non-U.S. citizens as patientscitizens as patients
Open hospitals in other Open hospitals in other countriescountries
Competitive StrategiesCompetitive Strategies More aggressive billing practices / More aggressive billing practices /
charging the uninsured higher pricescharging the uninsured higher prices Result: class action suitsResult: class action suits
Increase cash services (botox Increase cash services (botox treatments, cosmetic surgery) and treatments, cosmetic surgery) and re-imburseable, covered services re-imburseable, covered services (e.g., cardiac catheterization, bone (e.g., cardiac catheterization, bone density testing)density testing)
Competitive StrategiesCompetitive Strategies Cut back on uncovered services: Cut back on uncovered services:
e.g., ER staffinge.g., ER staffing ““Triaging out” – redirecting low Triaging out” – redirecting low
acuity patients to ER to “other acuity patients to ER to “other facilities”facilities” University of Chicago overturned policy University of Chicago overturned policy
in response to protests (2009)in response to protests (2009) ACEP and AAEM opposes such policiesACEP and AAEM opposes such policies
Competitive StrategiesCompetitive Strategies AdvertisingAdvertising
Often promote high-paying, unproved, Often promote high-paying, unproved, or cosmetic servicesor cosmetic services
Arch Int Med 2005;165:645-51Arch Int Med 2005;165:645-51 Outsource radiology/transcription Outsource radiology/transcription
services to physicians in developing services to physicians in developing worldworld e.g., MGH and Yale X-rays e.g., MGH and Yale X-rays →→ India India
(they have since ended agreements)(they have since ended agreements)
Competitive StrategiesCompetitive Strategies Pay sports teams for privilege of being Pay sports teams for privilege of being
team doctors (in return for free team doctors (in return for free publicity)publicity) Methodist Hospital – Houston TexansMethodist Hospital – Houston Texans NYU Hospital for Joint Diseases – NY NYU Hospital for Joint Diseases – NY
MetsMets Develop luxury primary care clinicsDevelop luxury primary care clinics
AKA “executive health clinics”, AKA “executive health clinics”, “boutique medicine”, “concierge “boutique medicine”, “concierge care”, “VIP clinics”care”, “VIP clinics”
Recruitment of Wealthy Recruitment of Wealthy Non-US CitizensNon-US Citizens
70,000 patients/yr70,000 patients/yr Estimated 1-2% of hospitals’ revenuesEstimated 1-2% of hospitals’ revenues Number estimated to quadruple in Number estimated to quadruple in
next few yearsnext few years Recruitment worldwideRecruitment worldwide Hospitals forming consortia to target Hospitals forming consortia to target
certain countries, including those with certain countries, including those with national health plansnational health plans
Recruitment of Wealthy Recruitment of Wealthy Non-US CitizensNon-US Citizens
Doctors sent on overseas Doctors sent on overseas speaking and recruitment speaking and recruitment tourstours
Patients offered rapid access Patients offered rapid access to state-of-the-art careto state-of-the-art care
Recruitment of Wealthy Recruitment of Wealthy Non-US CitizensNon-US Citizens
Payment at “retail rate,” well Payment at “retail rate,” well above what government and above what government and private insurance reimburseprivate insurance reimburse
Immediate access to face-to-face Immediate access to face-to-face translatorstranslatorsOnly spottily available to Only spottily available to
uninsured, non-English speaking uninsured, non-English speaking patientspatients
Recruitment of Wealthy Recruitment of Wealthy Non-US CitizensNon-US Citizens
Patients have not paid taxes in support Patients have not paid taxes in support of medical education and health care of medical education and health care subsidiessubsidies The federal government spends The federal government spends
about $10 billion/yr to pay medical about $10 billion/yr to pay medical schools and teaching hospitals for schools and teaching hospitals for medical education and trainingmedical education and training
State and local governments provide State and local governments provide $2-3 billion/yr in additional subsidies$2-3 billion/yr in additional subsidies
Recruitment of Wealthy Recruitment of Wealthy Non-US CitizensNon-US Citizens
Health needs may not be as Health needs may not be as pressing (and are usually pressing (and are usually more costly) than the needs more costly) than the needs of those living in poverty in of those living in poverty in their home countriestheir home countries
Recruitment of Wealthy Recruitment of Wealthy Non-US CitizensNon-US Citizens
Academic medical centers often refuse Academic medical centers often refuse non-emergent care to non-US citizen non-emergent care to non-US citizen refugees and undocumented aliensrefugees and undocumented aliens
Reason: Fear of depletion of financial Reason: Fear of depletion of financial resourcesresourcesCosts of care itselfCosts of care itselfDevelopment of informal referral Development of informal referral
basebase
Overseas Clinics and Overseas Clinics and HospitalsHospitals
Academic medical centers owning Academic medical centers owning and/or operating clinics and hospitals and/or operating clinics and hospitals overseasoverseas
Examples:Examples: Cleveland Clinic: Abu Dhabi, UAECleveland Clinic: Abu Dhabi, UAE Duke University: Duke-National Duke University: Duke-National
University of SingaporeUniversity of Singapore Johns Hopkins: Cancer center in Johns Hopkins: Cancer center in
Singapore International Medical CenterSingapore International Medical Center
Overseas Clinics and Overseas Clinics and HospitalsHospitals
Examples:Examples: Mayo Clinic : DubaiMayo Clinic : Dubai Cornell-Weill Medical College: QatarCornell-Weill Medical College: Qatar University of Pittsburgh: transplant University of Pittsburgh: transplant
center in Palermo, Sicily, Italycenter in Palermo, Sicily, Italy MD Anderson Cancer Center: MD MD Anderson Cancer Center: MD
Anderson International-EspaAnderson International-España in Madrid, ña in Madrid, SpainSpain
Boutique MedicineBoutique Medicine Retainer Fee Medical PracticeRetainer Fee Medical Practice
Large/expensive vs. small/less Large/expensive vs. small/less expensive (sometimes for the expensive (sometimes for the uninsured; not the focus of this uninsured; not the focus of this talk)talk)
Premier Care, Valet Care, VIP Care, Premier Care, Valet Care, VIP Care, Gold Care, Platinum CareGold Care, Platinum Care
Luxury Primary Care / Executive Luxury Primary Care / Executive Health ClinicsHealth Clinics
Boutique MedicineBoutique Medicine Medi-SpasMedi-Spas
Cosmetic procedures, massage, Cosmetic procedures, massage, aromatherapy, cosmeceutical salesaromatherapy, cosmeceutical sales
Generate over $1 billion annually in USGenerate over $1 billion annually in US Travel medicine clinics for exotic Travel medicine clinics for exotic
destinationsdestinations Direct sales to patients of health and Direct sales to patients of health and
nutritional products, home laboratory nutritional products, home laboratory and genome testing kitsand genome testing kits
Other Specialized Other Specialized Primary Care ClinicsPrimary Care Clinics
Urgent care clinicsUrgent care clinics Retail outlet clinicsRetail outlet clinics On-site corporate clinicsOn-site corporate clinics
1,200 companies host 2,200 1,200 companies host 2,200 clinicsclinics
Serve 4% of working Serve 4% of working AmericansAmericans
Factors Which Might Factors Which Might Encourage Retainer Fee Encourage Retainer Fee
Medical PracticeMedical PracticeJ Clin Ethics 2005(Spring):72-84J Clin Ethics 2005(Spring):72-84
Tight office schedules, long Tight office schedules, long delays for appointments, delays for appointments, shorter visit lengthsshorter visit lengths
Authorization requirements of Authorization requirements of insurance companies, HMOs, insurance companies, HMOs, and Medicareand Medicare
Factors Which Might Factors Which Might Encourage Retainer Fee Encourage Retainer Fee
Medical PracticeMedical Practice Insufficient time to return phone Insufficient time to return phone
callscalls Congested ERs, with long delays Congested ERs, with long delays
for patients with minor illnesses for patients with minor illnesses who are unable to access PCPwho are unable to access PCP
Patients referred to specialists for Patients referred to specialists for problems that do not necessarily problems that do not necessarily require a specialist’s carerequire a specialist’s care
Factors Which Might Factors Which Might Encourage Retainer Fee Encourage Retainer Fee
Medical PracticeMedical Practice Frequent changes in PCP, abetted by:Frequent changes in PCP, abetted by:
Hospitalist movementHospitalist movement Employers seeking cheaper plans, which Employers seeking cheaper plans, which
provide narrower range of coverageprovide narrower range of coverage Insurance company de-listing of Insurance company de-listing of
physicians based on economic criteriaphysicians based on economic criteria Physician extenders (NPs and Pas)Physician extenders (NPs and Pas) Less time for patient-care advocacyLess time for patient-care advocacy Less time for CMELess time for CME
Luxury Primary Care Luxury Primary Care ClinicsClinics
Some are solo and small group Some are solo and small group practicespractices
5,000 physicians (includes “hybrid” 5,000 physicians (includes “hybrid” and “direct primary care” practices) and “direct primary care” practices)
Some affiliated with large corporationsSome affiliated with large corporationsExecutive Health RegistryExecutive Health RegistryExecutive Health Exams Executive Health Exams
InternationalInternationalOneMDOneMD
Luxury Primary Care Luxury Primary Care ClinicsClinics
MDVIPMDVIP Mission: “Assist doctors in Mission: “Assist doctors in
transitioning from traditional to transitioning from traditional to retainer-style practices”retainer-style practices”
Phenomenal growth ratePhenomenal growth rate 24 practices in 7 states, with 40 24 practices in 7 states, with 40
more practices in the worksmore practices in the works Purchased by Procter and GamblePurchased by Procter and Gamble
Luxury Primary CareLuxury Primary Care Professional Organization:Professional Organization:
American Society of American Society of Concierge Physicians Concierge Physicians (ASCP) (ASCP) →→
Society for Innovative Medical Practice Design (SIMPD)
Luxury Primary Care Luxury Primary Care ClinicsClinics
University-affiliated:University-affiliated:Mayo Clinic (3000/yr); Mayo Clinic (3000/yr);
Cleveland Clinic (3500/yr); MGH Cleveland Clinic (3500/yr); MGH (1950/yr)(1950/yr)
Johns Hopkins, Penn, New York Johns Hopkins, Penn, New York Presbyterian, Washington Presbyterian, Washington University, UCSF, UCLA, many University, UCSF, UCLA, many othersothers
Luxury Primary Care Luxury Primary Care ClinicsClinics
Annual exams last 1-2 daysAnnual exams last 1-2 days Average baseline cost $2000 - Average baseline cost $2000 -
$4000 per visit for baseline package$4000 per visit for baseline package Additional tests extraAdditional tests extra (range $1500 - $20,000)(range $1500 - $20,000)
Physicians available 24/7/365 by Physicians available 24/7/365 by phone/pager for additional feephone/pager for additional fee
Luxury Primary Care Luxury Primary Care ClinicsClinics
Some physicians take no insurance, Some physicians take no insurance, only direct payments (“direct primary only direct payments (“direct primary care”)care”)
Patient/physician ratios 10-25% of Patient/physician ratios 10-25% of typical managed care levelstypical managed care levelsPhysicians cut current panel size, Physicians cut current panel size,
but often keep some patients, but often keep some patients, including the uninsured (“hybrid including the uninsured (“hybrid practice”)practice”)
Luxury Primary Care Luxury Primary Care Clinics:Clinics:
Perks and PamperingPerks and Pampering Tests, subspecialty consultations Tests, subspecialty consultations
available same dayavailable same dayPatients jump the queue, Patients jump the queue,
sometimes delaying tests on sometimes delaying tests on other patients with more other patients with more appropriate and urgent needsappropriate and urgent needsSpecial shirtsSpecial shirtsGold cardsGold cards
Luxury Primary Care Luxury Primary Care Clinics:Clinics:
Perks and PamperingPerks and Pampering Vaccines (in short supply Vaccines (in short supply
elsewhere) always availableelsewhere) always available
Valet parkingValet parking
EscortsEscorts
Plush bathrobesPlush bathrobes
Luxury Primary Care Luxury Primary Care Clinics:Clinics:
Perks and PamperingPerks and Pampering Oak-paneled waiting rooms with high-Oak-paneled waiting rooms with high-
backed leather chairs and fine artbacked leather chairs and fine art
TVs, computers, fax machinesTVs, computers, fax machines
Buffet meals, herb teasBuffet meals, herb teas
Saunas and massagesSaunas and massages
Luxury Primary Care Luxury Primary Care ClinicsClinics
Capitalize on widespread Capitalize on widespread dissatisfaction with managed care dissatisfaction with managed care and too-busy physicians with and too-busy physicians with inadequate time to provide inadequate time to provide comprehensive care and counselingcomprehensive care and counseling
Appeal to patients’ desires to receive Appeal to patients’ desires to receive the latest high-tech diagnostic and the latest high-tech diagnostic and therapeutic interventionstherapeutic interventions
Clients / PatientsClients / Patients Predominantly healthy / asymptomaticPredominantly healthy / asymptomatic US and non-US citizensUS and non-US citizens Corporate executivesCorporate executives
Some from companies with extensive Some from companies with extensive histories of harming health through histories of harming health through environmental pollution, tobacco salesenvironmental pollution, tobacco sales
Some from insurance companies, whose Some from insurance companies, whose own policies increasingly limit the own policies increasingly limit the coverage of sick individuals, including coverage of sick individuals, including their own lower level employeestheir own lower level employees
Clients / Patients:Clients / Patients:Upper ManagementUpper Management
Disproportionately white males:Disproportionately white males: Data available from one Executive Data available from one Executive
Health ProgramHealth Program Women:Women:
46% of the workforce46% of the workforceHold Hold < 2% of senior-level < 2% of senior-level management positions in Fortune management positions in Fortune 500 Companies500 Companies
Lower SES of non-CaucasiansLower SES of non-Caucasians
Luxury Primary Care:Luxury Primary Care:MarketingMarketing
Directed at the heads of large and Directed at the heads of large and small companiessmall companies
Hospitals hope high-level managers Hospitals hope high-level managers will steer their companies’ lucrative will steer their companies’ lucrative health care contracts toward the health care contracts toward the institution and its providersinstitution and its providers
Some programs give discounted rates Some programs give discounted rates in exchange for a donation to the in exchange for a donation to the hospitalhospital
Luxury Primary Care:Luxury Primary Care:MarketingMarketing
Promotional materials imply that Promotional materials imply that wealthy executives are busier and wealthy executives are busier and lead more hectic lives than otherslead more hectic lives than others We cater to “the busy executive” who We cater to “the busy executive” who
“demands only the best”“demands only the best” In fact, lower SES patients’ lives are In fact, lower SES patients’ lives are
often busier and their health often busier and their health outcomes worse, rendering them in outcomes worse, rendering them in greater need of efficient, greater need of efficient, comprehensive carecomprehensive care
Programs are SecretivePrograms are Secretive Stating that I was a physician Stating that I was a physician
researching the phenomenon of LPC researching the phenomenon of LPC clinics, I wrote and then called 13 LPC clinics, I wrote and then called 13 LPC clinicsclinics
Only one person at one clinic would Only one person at one clinic would answer basic questions relating to the answer basic questions relating to the # of providers, involvement of # of providers, involvement of residents, funding, cross-subsidizationresidents, funding, cross-subsidization
LPC Clinics and The LPC Clinics and The Erosion of ScienceErosion of Science
Many tests not clinically- or Many tests not clinically- or cost-effectivecost-effectivePercent body fat Percent body fat measurementsmeasurements
Chest X rays in smokers and Chest X rays in smokers and non-smokers over age 35 to non-smokers over age 35 to screen for lung cancerscreen for lung cancer
LPC Clinics and The LPC Clinics and The Erosion of ScienceErosion of Science
Electron-beam CT scans and stress Electron-beam CT scans and stress echocardiograms for coronary artery echocardiograms for coronary artery diseasedisease Radiation from a full-body CT scan Radiation from a full-body CT scan
comparable to dose with increased cancer comparable to dose with increased cancer mortality in low-dose atomic bomb survivors mortality in low-dose atomic bomb survivors (Radiology 2004;232:735-8)(Radiology 2004;232:735-8)
Raise cancer riskRaise cancer risk Abdominal-pelvic ultrasounds to screen Abdominal-pelvic ultrasounds to screen
for liver and ovarian cancerfor liver and ovarian cancer
LPC Clinics and The LPC Clinics and The Erosion of ScienceErosion of Science
Other tests controversialOther tests controversial Genetic testingGenetic testing Mammograms in women beginning Mammograms in women beginning
at age 35at age 35 False positive tests may lead to False positive tests may lead to
unnecessary investigations, higher unnecessary investigations, higher costs and needless anxietycosts and needless anxiety And increased profits to the clinic…..And increased profits to the clinic…..
Direct Marketing of High-Direct Marketing of High-Tech Tests to PatientsTech Tests to Patients
Ameriscan:Ameriscan: Full body scans: “detect over 100 Full body scans: “detect over 100
life-threatening diseases in the life-threatening diseases in the arteries, heart, lungs, liver and other arteries, heart, lungs, liver and other major vital organs – before it’s too major vital organs – before it’s too late”late”
MRI breastscreens: detect “nearly MRI breastscreens: detect “nearly 100% of all breast cancers”100% of all breast cancers”
Virtual colonoscopiesVirtual colonoscopies
The Use of Clinically-The Use of Clinically-Unjustifiable TestsUnjustifiable Tests
Erodes the scientific underpinnings of Erodes the scientific underpinnings of medical practicemedical practice
Sends a mixed message to trainees Sends a mixed message to trainees about when and why to utilize about when and why to utilize diagnostic studiesdiagnostic studies
Runs counter to physicians’ ethical Runs counter to physicians’ ethical obligations to contribute to the ethical obligations to contribute to the ethical stewardship of health care resourcesstewardship of health care resources
The Use of Clinically-The Use of Clinically-Unjustifiable TestsUnjustifiable Tests
Some might argue that if a patient is willing Some might argue that if a patient is willing to pay for a scientifically-unsupported test to pay for a scientifically-unsupported test that she should be allowed to do so. that she should be allowed to do so. However,However, ““Buffet” approach to diagnosis makes a Buffet” approach to diagnosis makes a
mockery of evidence-based medical caremockery of evidence-based medical care Diverts hardware and technician time Diverts hardware and technician time
away from patients with more appropriate away from patients with more appropriate and possibly urgent indications for testingand possibly urgent indications for testing
Ethics/Justice:Ethics/Justice:Treating Patients from Treating Patients from
OverseasOverseas The greatest good for the The greatest good for the
greatest numbergreatest numberLiver transplant for wealthy Liver transplant for wealthy foreign banker vs. treating foreign banker vs. treating undocumented farm undocumented farm laborers for TB and laborers for TB and pesticide-related diseasespesticide-related diseases
Ethics/Justice:Ethics/Justice:Treating Patients OverseasTreating Patients Overseas
Deploying medical students and Deploying medical students and physicians overseas to provide physicians overseas to provide care and educate local care and educate local practitioners in the care of practitioners in the care of respiratory and water-borne respiratory and water-borne infectious diseasesinfectious diseasesKill thousands worldwide each Kill thousands worldwide each dayday
Ethics/JusticeEthics/Justice Market forces have spurred Market forces have spurred
for-profit health care for-profit health care companies to export the most companies to export the most inefficient, unjust elements of inefficient, unjust elements of American medicine to the American medicine to the developing worlddeveloping world
Ethics/JusticeEthics/Justice Migration of medical professionals from Migration of medical professionals from
the developing world, where they were the developing world, where they were trained at public expense, to the US trained at public expense, to the US further depletes health care resources in further depletes health care resources in poor countries and contributes to poor countries and contributes to increasing inequities between rich and increasing inequities between rich and poor nationspoor nations
US patients going abroad for US patients going abroad for procedures; medical tourism; supported procedures; medical tourism; supported by many insurance companiesby many insurance companies
The Medical Brain DrainThe Medical Brain Drain 1998 UN/WHO Study: 56% of all 1998 UN/WHO Study: 56% of all
migrating doctors flow from developing migrating doctors flow from developing to developed nations, while only 11% to developed nations, while only 11% migrate in the opposite directionmigrate in the opposite direction 2007: WHO estimates 2.4 million too 2007: WHO estimates 2.4 million too
few physuicians, nurses, and few physuicians, nurses, and midwives to provide essential health midwives to provide essential health services to developing worldservices to developing world
U.S. largest “consumer” of health U.S. largest “consumer” of health workers from the developing worldworkers from the developing world
Even greater imbalance for nursesEven greater imbalance for nurses
The Medical Brain DrainThe Medical Brain Drain Health care and financial loss to Health care and financial loss to
developing country; gain for developing country; gain for developed countrydeveloped country
Example of “inverse care law”:Example of “inverse care law”:Those countries that need the Those countries that need the
most health care resources are most health care resources are getting the leastgetting the least
LPC Clinics and The LPC Clinics and The Erosion of Professional Erosion of Professional
EthicsEthics Public contributes substantially to the Public contributes substantially to the
education and training of new education and training of new physiciansphysiciansMay object to doctors limiting their May object to doctors limiting their
practices to the wealthy, not practices to the wealthy, not accepting Medicare or Medicaid accepting Medicare or Medicaid patientspatients
Increases health disparities between Increases health disparities between rich and poorrich and poor
LPC Clinics and The LPC Clinics and The Erosion of Professional Erosion of Professional
EthicsEthics Alternatively, debt-ridden Alternatively, debt-ridden
physicians might justify limiting physicians might justify limiting their practices to the wealthy by their practices to the wealthy by claiming a right to freely choose claiming a right to freely choose where they practice and for where they practice and for whom they carewhom they care Limits: HIV patients, racial Limits: HIV patients, racial
prejudiceprejudice
LPC Clinics and The LPC Clinics and The Erosion of Professional Erosion of Professional
EthicsEthics Academic medical centers’ justifications for Academic medical centers’ justifications for
LPC clinics:LPC clinics: Enhance plurality in health care delivery; Enhance plurality in health care delivery;
increase choices available to health care increase choices available to health care consumersconsumers
Cross-subsidization of training or indigent Cross-subsidization of training or indigent care programscare programs Tufts, Virginia-MasonTufts, Virginia-Mason Otherwise, evidence lacking due to Otherwise, evidence lacking due to
secrecysecrecy Variant of “trickle down economics”Variant of “trickle down economics”
LPC Clinics and The LPC Clinics and The Erosion of Professional Erosion of Professional
EthicsEthics AMA Guidelines:AMA Guidelines:
Physicians switching to LPC Physicians switching to LPC practices must facilitate the transfer practices must facilitate the transfer of patients who don’t pay retainers of patients who don’t pay retainers to other physiciansto other physiciansShifts un- and poorly-compensated Shifts un- and poorly-compensated patient care onto fewer providers; patient care onto fewer providers; risks domino effectrisks domino effect
LPC Clinics and The LPC Clinics and The Erosion of Professional Erosion of Professional
EthicsEthics AMA Guidelines:AMA Guidelines:
If non-retainer care is not locally available, If non-retainer care is not locally available, physicians may be obligated to continue to care physicians may be obligated to continue to care for patients without charging them a premiumfor patients without charging them a premium
Physicians with boutique practices are also still Physicians with boutique practices are also still obligated to provide care to patients in needobligated to provide care to patients in need ““Robin Hood practices”Robin Hood practices”
Retainer-style practices shouldn’t be marketed Retainer-style practices shouldn’t be marketed as providing better diagnostic and therapeutic as providing better diagnostic and therapeutic servicesservices
Ethics/JusticeEthics/Justice 45 million uninsured patients in US45 million uninsured patients in US Millions more underinsuredMillions more underinsured
Remain in dead-end jobsRemain in dead-end jobsGo without needed prescriptions Go without needed prescriptions
due to skyrocketing drug pricesdue to skyrocketing drug prices Public and charity hospitals closingPublic and charity hospitals closing
Ethics/JusticeEthics/Justice Retail outlet clinics increasing (Wal Retail outlet clinics increasing (Wal
Mart, CVS, etc.)Mart, CVS, etc.) Approximately 1200 currentlyApproximately 1200 currently Mechanism for increasing stores’ profits Mechanism for increasing stores’ profits
through sales of merchandise, over-priced through sales of merchandise, over-priced pharmaceuticalspharmaceuticals
Less likely to be located in underserved Less likely to be located in underserved areasareas
No guarantee of continuity of careNo guarantee of continuity of care Most not profitableMost not profitable
Retail Outlet ClinicsRetail Outlet Clinics Study of visits for OM, pharyngitis, and Study of visits for OM, pharyngitis, and
UTIUTI Ann Int Med 2009;151:321-8.Ann Int Med 2009;151:321-8.
Quality same as in physician offices and Quality same as in physician offices and urgent care clinics, better than in ERurgent care clinics, better than in ER
Prescription costs similarPrescription costs similar Overall costs significantly lowerOverall costs significantly lower Convenience factorConvenience factor
Headline from Headline from The OnionThe Onion
Uninsured Man Hopes His Uninsured Man Hopes His Symptoms Diagnosed This Symptoms Diagnosed This
Week On Week On HouseHouse
Ethics/JusticeEthics/Justice US ranks near the bottom among US ranks near the bottom among
westernized nations in life westernized nations in life expectancy and infant mortalityexpectancy and infant mortality
20-25% of US children live in 20-25% of US children live in povertypoverty
Gap between rich and poor wideningGap between rich and poor widening Racial inequalities in processes and Racial inequalities in processes and
outcomes of care persistoutcomes of care persist
Ethics/JusticeEthics/Justice Widening disparity between what Widening disparity between what
hospitals charge uninsured and self-hospitals charge uninsured and self-pay patients compared with insured pay patients compared with insured patientspatients
Private hospitals charging more than Private hospitals charging more than public hospitals for end-of-life carepublic hospitals for end-of-life care No effect on outcomes, quality of lifeNo effect on outcomes, quality of life
Meanwhile, Outside the Meanwhile, Outside the US…US…
One billion people lack access to One billion people lack access to clean drinking waterclean drinking water
3 billion lack adequate 3 billion lack adequate sanitation servicessanitation services
Hunger kills as many individuals Hunger kills as many individuals in two days as died during the in two days as died during the atomic bombing of Hiroshimaatomic bombing of Hiroshima
Physician Physician Dissatisfaction/Cynicism/ErDissatisfaction/Cynicism/Er
osion of Professionalismosion of Professionalism Increasing dissatisfaction and Increasing dissatisfaction and
cynicism among patients, practicing cynicism among patients, practicing physicians and traineesphysicians and trainees
Educators increasingly concerned Educators increasingly concerned over adequacy of trainees’ over adequacy of trainees’ humanistic and moral developmenthumanistic and moral development
Ethical DistortionsEthical Distortions Doctors offering varying Doctors offering varying
levels of testing and levels of testing and treatment based on patient’s treatment based on patient’s ability to payability to pay J Gen Int Med 2001;16:412-8.J Gen Int Med 2001;16:412-8.Surprise?Surprise?
Doctor-Patient Doctor-Patient Communication re Out-of-Communication re Out-of-
Pocket CostsPocket Costs 15-20% of U.S. health care costs 15-20% of U.S. health care costs
paid by patients out-of-pocketpaid by patients out-of-pocket Physician-patient communication Physician-patient communication
hindered by discomfort (patients) hindered by discomfort (patients) and perceived lack of and perceived lack of time/nihilism (physicians)time/nihilism (physicians)
Relevant/importantRelevant/important
Ethical DistortionsEthical Distortions A sizeable minority of physicians A sizeable minority of physicians
admit to “gaming the system” by admit to “gaming the system” by manipulating reimbursement manipulating reimbursement rules so their patients can rules so their patients can receive care the doctors receive care the doctors perceive is necessaryperceive is necessary JAMA 2000;238:1858-65JAMA 2000;238:1858-65 Arch Int Med 2002;162:1134-9Arch Int Med 2002;162:1134-9
Ethical DistortionsEthical Distortions ¼ of the public sanctions ¼ of the public sanctions
deception; ½ of those who deception; ½ of those who believe doctors have believe doctors have inadequate time to appeal inadequate time to appeal coverage decisionscoverage decisions Ann Int Med 2003;138:472-5Ann Int Med 2003;138:472-5 Am J Bioethics 2004;4(4):1-7Am J Bioethics 2004;4(4):1-7
Conclusion:Conclusion:Erosion of ScienceErosion of Science
LPC clinics offer care based on LPC clinics offer care based on unsound science and non-evidence-unsound science and non-evidence-based medicinebased medicine
Motives:Motives: MarketabilityMarketability ProfitabilityProfitability Patient satisfaction/demandPatient satisfaction/demand
Potential for harmPotential for harm
Conclusion:Conclusion:Erosion of EthicsErosion of Ethics
The promotion of LPC clinics The promotion of LPC clinics and the recruitment of wealthy and the recruitment of wealthy foreigners by academic medical foreigners by academic medical centers erodes fundamental centers erodes fundamental ethical principles of equity and ethical principles of equity and justice and promotes an overt, justice and promotes an overt, two-tiered system of health caretwo-tiered system of health care
SolutionsSolutions Renounce the marketplace as Renounce the marketplace as
dominant standard or value in dominant standard or value in medicinemedicine
Divert intellectual and financial Divert intellectual and financial resources to more equitable resources to more equitable and just investments in and just investments in community and global healthcommunity and global health
SolutionsSolutions Close some academic medical Close some academic medical
centerscenters
Consolidate redundant Consolidate redundant educational and clinical educational and clinical programs in nearby teaching programs in nearby teaching hospitalshospitals
SolutionsSolutions Reduce costs throughReduce costs through
Quality improvement programsQuality improvement programs Improved governance and decision-Improved governance and decision-
makingmaking Augmenting philanthropic Augmenting philanthropic
contributionscontributions Increasing alliances with industry?Increasing alliances with industry?
Risks undue corporate influence on Risks undue corporate influence on academic institutions’ agendasacademic institutions’ agendas
SolutionsSolutions Improved training and practice Improved training and practice
of professionalism in medicineof professionalism in medicine Heal schism between medicine Heal schism between medicine
and public healthand public health Service-oriented learning, Service-oriented learning,
research-based activist courses, research-based activist courses, volunteerism, political activismvolunteerism, political activism
SolutionsSolutionsHistory and literatureHistory and literature
Role models/mentorsRole models/mentors
Refocus ethics trainingRefocus ethics training
SolutionsSolutions Empathic and equal provision of care Empathic and equal provision of care
to all individuals, regardless of to all individuals, regardless of insurance status, financial resources, insurance status, financial resources, race or sexrace or sex
Confront and work to abolish the Confront and work to abolish the reality of rationing; promote equal reality of rationing; promote equal access and care in all spheres of access and care in all spheres of medicinemedicine
SolutionsSolutions Educate public and policymakers Educate public and policymakers
regarding the important roles regarding the important roles they play in research, education they play in research, education and patient careand patient careParticularly in terms relevant to Particularly in terms relevant to individuals and their familiesindividuals and their families
SolutionsSolutions Communicate these ideas to Communicate these ideas to
business leaders, government business leaders, government representatives, and representatives, and purchasers of health carepurchasers of health careparticularly deans, hospital particularly deans, hospital presidents and department presidents and department chairschairs
SolutionsSolutions Society/legislators should provide Society/legislators should provide
increased funding for the education increased funding for the education and training of medical students and and training of medical students and resident physicians and for the resident physicians and for the continued health of vital academic continued health of vital academic medical centers, to allow them to medical centers, to allow them to carry out their missions of education, carry out their missions of education, research, and patient care, research, and patient care, particularly for the underservedparticularly for the underserved
ReferencesReferences Donohoe MT. “Standard vs. luxury care,” Donohoe MT. “Standard vs. luxury care,”
in in Ideological Debates in Family MedicineIdeological Debates in Family Medicine, , S S Buetow and T Kenealy, Eds. (Buetow and T Kenealy, Eds. (New York, New York, Nova Science Publishers, Inc., 2007). Nova Science Publishers, Inc., 2007). Available at Available at http://phsj.org/?page_id=22
Donohoe MT. Elements of professionalism Donohoe MT. Elements of professionalism for a physician considering the switch to a for a physician considering the switch to a retainer practice. In retainer practice. In Professionalism in Professionalism in Medicine: The Case-based Guide for Medicine: The Case-based Guide for Medical StudentsMedical Students, Editors: Spandorfer, , Editors: Spandorfer, Pohl, Rattner, and Nasca (Cambridge Pohl, Rattner, and Nasca (Cambridge University Press, 2008, in press).University Press, 2008, in press).
ReferencesReferences Donohoe MT. Luxury primary care, Donohoe MT. Luxury primary care,
academic medical centers, and the academic medical centers, and the erosion of science and professional ethics. erosion of science and professional ethics. J Gen Int Med 2004;19:90-94. Available at J Gen Int Med 2004;19:90-94. Available at http://www.blackwell-synergy.com/doi/pdf/10.1111/j.1525-1497.2004.20631.x
Donohoe MT. Retainer practice: Scientific Donohoe MT. Retainer practice: Scientific issues, social justice, and ethical issues, social justice, and ethical perspectives. American Medical perspectives. American Medical Association Virtual Mentor 2004 Association Virtual Mentor 2004 (April);6(4). Available at (April);6(4). Available at http://www.ama-assn.org/ama/pub/category/12249.html
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